(SEE RULE 9)

APPLICATION FOR GRANT FROM W.P BENEVOLENT FUND FOR

GOVERNMENT SERVANTS
1. Name of Government Servant
2. Date of entry into Government
Service
3. Date of Death, invalidation or
retirement.
4. Total Length of Service at the time
of this application
5.
a. Post at the Time of this
application retirement or death.
b. Weather such post gazzated.
c. Weather the Government Servant
held such post permanently or
temporarily.
6. Last pay drawn and Scale of pay.
7.
a. Details of dependant family
members such as their names,
ages, weather married or un-
married, school or college where
being educated, relationship of
each with Government Servant.
b. Details of earning family members
not included in item (a) above &
their monthly income.
8. Details of property left by
Government Servant for his
dependant.
a. Move-able including cash.
b. Immovable.
9. Amount & Date from which
gratuity / communication has been
granted by the Government.
10. If insured, the amount for which
insured.
11. Total G.P Fund accumulations
12.
(1) Date from which contributing
to the Benevolent Fund.
(2) Total Contribution towards
Benevolent Fund.
13. Amount applied for
14. Reasons for the application with
proof, if any
15. In case application by Widow, a
statement to the affect date She
has not re-married
 I do hereby affirm and verify that contents of the above application or correct to
the best of my knowledge and belief and that I have concealed nothing.

I know that in the event of making a willful misrepresentation of supersession of

fact, I shall be liable to criminal prosecution.

Signature __________________________

Name of the Applicant ________________

__________________________________

Address ____________________________

___________________________________

I certify and attest the details furnished above from the regard available in this office and

(i) Recommended .
(ii) Do not recommend for the reasons .

Signature & name

of Officer with Official Seal

Signature & name of Officer with Official Seal